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This study examined the effectiveness and feasibility of therapist-guided Internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N=18), BA (N=17), or a waiting-list (N=12). Treatment groups received 6 homework assignments over 6 to 8weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination, and brooding levels relative to the control group at posttreatment (d=0.7-1.2). BA lowered complicated grief, posttraumatic stress, and grief rumination levels at posttreatment (d=0.8-0.9). At 3-month follow-up, effects of EX were maintained on complicated grief and grief rumination (d=0.6-1.2), and for BA on complicated grief, posttraumatic stress, and grief rumination (d=0.8-0.9). EX reduced depression more strongly than BA (d=0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.

Background: There are now over 800,000 registered deaths due to the COVID-19 pandemic worldwide. Researchers have suggested that COVID-19 death characteristics (e.g., intensive care admission, unexpected death) and circumstances (e.g., secondary stressors, social isolation) will precipitate a worldwide increase of prolonged grief disorder (PGD) and persistent complex bereavement disorder (PCBD). Yet, no study has investigated this. Since acute grief is a strong predictor of future pathological grief, we compared grief levels among people recently bereaved due to COVID-19, natural, and unnatural causes. Methods: People bereaved through COVID-19 (n = 49), natural causes (n = 1182), and unnatural causes (n = 210), completed self-report measures of demographic and loss-related characteristics and PGD and PCBD symptoms. Results: COVID-19 bereavement yielded higher symptom levels of PGD (d = 0.42) and PCBD (d = 0.35) than natural bereavement (but not unnatural bereavement). Effects held when limiting analyses to recent losses and those who participated during the pandemic. Expectedness of the death explained this effect. Limitations: Limitations include using a convenience sample and self-report measures. Conclusions: Higher grief levels occur among people bereaved due to COVID-19 compared to people bereaved due to natural loss. We predict that pandemic-related increases in pathological grief will become a worldwide public health concern.

Ruminative coping has been associated with negative outcomes in bereavement. Rather than assuming it to be a problematic confrontation process, researchers have recently suggested rumination to be maladaptive through its links with avoidance processes. The main aim of this study was to examine, for the first time, whether the relationship between ruminative coping and symptoms of complicated grief and depression is mediated by avoidance processes (suppression, memory/experiential avoidance, behavioral avoidance, loss-reality avoidance). A sample of 282 adults (88% female, 12% male), bereaved on average 18 months previously, filled out three questionnaires at 6-month intervals. We assessed symptom levels, grief rumination, and trait rumination at baseline; avoidance processes after 6 months; and symptom levels after 12 months. When controlling for initial symptom levels, experiential avoidance mediated the link between grief rumination and complicated grief, and experiential avoidance and behavioral avoidance mediated the link between grief rumination and depression. Post hoc analyses showed suppression may also mediate the link between grief rumination and symptoms of complicated grief, but not depression. Loss-reality avoidance was no significant mediator of these relationships. This study provides initial evidence that rumination during bereavement increases and perpetuates symptoms of psychopathology, because it is linked with specific avoidance processes. Bereaved individuals with problematic grief and (chronic) rumination may benefit from therapy focused on countering avoidance tendencies.

Two different types of ruminative coping, depressive rumination and grief rumination, negatively influence bereavement outcome. Although grief-specific rumination is likely to be relevant in the bereavement context no internationally validated scale to measure grief rumination exists. Therefore, the current contribution aims to validate the Utrecht Grief Rumination Scale (UGRS), a scale developed to measure grief-specific rumination, in an English sample. Psychometric properties of the English UGRS were compared with those in a Dutch sample. 204 British adults (89 % women, 11 % men), bereaved on average 16 months ago, and 316 Dutch adults (88 % women, 12 % men), bereaved on average 12 months ago, filled out online questionnaires. Different types of rumination (grief rumination, brooding, reflection, trait rumination) and symptoms of psychopathology (anxiety, depression, complicated grief) were measured. A correlated five factor model provided the best fit for the UGRS. Multi-group comparisons showed that the factor structures of the English and Dutch version of the UGRS were highly similar across language groups. The UGRS showed excellent reliability. Results further supported the construct, convergent, divergent and concurrent validity of the English UGRS. The psychometric properties of the Dutch UGRS corroborated these findings. The UGRS appears a valid instrument to assess grief-specific rumination in international research and may have potential applicability as a clinical instrument to assess rumination in individuals with problematic grief.